Provider Demographics
NPI:1447994868
Name:OTIENO, EPHRAIM (MD)
Entity type:Individual
Prefix:DR
First Name:EPHRAIM
Middle Name:
Last Name:OTIENO
Suffix:
Gender:
Credentials:MD
Other - Prefix:
Other - First Name:
Other - Middle Name:
Other - Last Name:
Other - Suffix:
Other - Last Name Type:
Other - Credentials:
Mailing Address - Street 1:609 E MAIN ST APT 253
Mailing Address - Street 2:
Mailing Address - City:LOUISVILLE
Mailing Address - State:KY
Mailing Address - Zip Code:40202-1451
Mailing Address - Country:US
Mailing Address - Phone:859-625-2485
Mailing Address - Fax:
Practice Address - Street 1:550 S JACKSON ST FL STREET3
Practice Address - Street 2:
Practice Address - City:LOUISVILLE
Practice Address - State:KY
Practice Address - Zip Code:40202-1622
Practice Address - Country:US
Practice Address - Phone:502-852-5666
Practice Address - Fax:
Is Sole Proprietor?:Yes
Enumeration Date:2022-04-21
Last Update Date:2025-04-30
Deactivation Date:
Deactivation Code:
Reactivation Date:
Provider Licenses
StateLicense IDTaxonomies
390200000X
KY0000000207R00000X
Provider Taxonomies
Primary?CodeTypeClassificationSpecialization
Yes207R00000XAllopathic & Osteopathic PhysiciansInternal Medicine
No390200000XStudent, Health CareStudent in an Organized Health Care Education/Training Program